There are various formats for completing a process recording. The following is an outline that covers the major areas we want included within a process recording. Please utilize the template that follows for completing a process recording with an individual, couple or family client(s).

1. Description/Identifying Information: The social work student’s name, date of the interview and the date of submission to the field instructor should always be included. Identify the client, always remembering to disguise client name to protect confidentiality. Include the number of times this client has been seen (i.e., “Fourth contact with Mrs. S.”). On a first contact include name and ages of the client(s) you have written about. If client is seen in location other then the agency say where client was seen.

2. Purpose and Goal for the Interview. Briefly state the purpose of the interaction and if there are any specific goals to be achieved, the nature of the presenting issues and/or referral.

3. Verbatim Dialogue (in the table below). A word-for-word description of what happened, as well as the student can recall, should be completed. This section does not have to include a full session of dialogue but should include a portion of dialogue. The field instructor and student should discuss what portions should be included in the verbatim dialogue.

4. Assessment of the Patient/Client/Consumer. This requires the student to describe the clients’ verbal and nonverbal reactions throughout the session. Consider everything that is occurring such as body language, facial expression, verbal outburst, etc.

5. The Student’s Feelings and Reactions to the Client System and to the Interview (in the table below). This requires the student to put into writing unspoken thoughts and reactions s/he had during the interview e.g. “I was feeling angry at what the client was saying, not sure why I was reacting this way…”. “ I wonder what would happen if I said such-and-such.”

6. Identify Skills and/or Theory/ Conceptual Frameworks used (in the table below). The student should be able to identify what skills they used in an interaction, and/or what theoretical framework came to mind as they dialogued e.g. “I used the strengths perspective “ “I used the skill of partializing”

7. Supervisor/field instructor comments (in the table below) This requires the field instructor to provide review and critique of the student’s dialogue with the client system, skill identification, and interpretation of the client interview.

8. A summary assessment/analysis of the student’s impressions. This is a summary of the student’s analytical thinking about the entire interview and/or any specific interaction the student is unsure about. Include any client action or non-verbal activity that the student may want to discuss. (See Guided Questions at the end of the template for this section A-M)

9. Future plans. The student should identify any unfinished business and/or any short/long term goals.

Process Recording Template

Student Name: Date of Contact:

Session number or Contact number: Location of the client interview:

1. Description of Client System (race/ethnicity, age, gender, employment status, education-level, ability status, military status, immigration status, marital status, household composition, religious affiliation):

1. Presenting Problem (Most people can tolerate a certain degree of hardship or physical/psychological discomfort before seeking help. What is the reason/problem/condition/circumstance/situation that motivates the client system to seek professional help from your field agency?):

1. Purpose of Session (Why is the client being seen by you at this time?):

1. Objectives/Goals of this session (What do you intend to do during this session to help the client system:

1. Centering (What did you do to be present in the moment with the client system – breathing activities, progressive muscle relaxation activities, mediating, praying, grounding activities, self-talk, removing distractions from the environment (e.g. turning ringer of telephone to vibrate/silence, silencing notifications from digital devices, turning on a white noise maker, setting the temperature to a comfortable setting, so forth).

1. Preparing (What did you do to prepare yourself to deliver competent practice with the client system during the interview?):

1. Orienting: (What information do you need to provide to inform the client system of the agency services, expectation for client sessions, average number of sessions, length of sessions, and location of sessions?): Process Recording Nursing Paper.

ADDITIONAL INFORMATION 

Process Recording in Nursing

Introduction

Process recording is a method for documenting the steps of an individual or group’s activities. It can be used during nursing care or to track patient progress. A process recording can be used to evaluate the quality of care provided by nursing staff, as well as assessing patient outcomes related to treatment procedures.

What is Process Recording?

What is process recording? Process recording is a written record of what happens during a nursing process. Process recording can be used to improve patient care, communicate with other healthcare professionals, document and assess the quality of care being provided to patients and their family members/caregivers.

Process recordings are also useful for documenting incidents or accidents that occur in the hospital setting or on other medical facilities such as long-term care homes or hospice programs.

Benefits of Process Recording

Process recording can be a valuable tool for nursing, particularly when you’re looking to improve the quality of care delivered. This is because it allows you to quickly identify gaps and opportunities for improvement in your patient’s experience.

When patients have access to this type of information, they may be able to take action on their own behalf (e.g., raising concerns with staff or requesting additional resources). In addition, using process recording will allow nurses an opportunity to develop better relationships with patients—and ultimately help them feel more at ease during their visits. In turn, this relationship will lead them into making better decisions while visiting the doctor or hospital; they’ll also provide more accurate feedback regarding how well things are going throughout their stay so that appropriate adjustments can be made moving forward.

Components of a Process Recording

Process recording is a way to document the nursing process. It’s a way to document the steps taken to provide care and it provides more detailed information than just notes, but it’s still not perfect.

Process recording involves taking notes about each step in a nursing process, from beginning until end, as well as any other relevant information needed for further documentation or reporting purposes (e.g., patient demographics).

Guidelines for Writing a Process Recording

The process recording must be written in the first person, using active verbs. It should also be clear and concise, and it should not use jargon or technical terms that might confuse the reader. The tone of your writing should be positive and professional throughout—it cannot sound too casual or informal at any point in your report.

The following guidelines will help you write a more effective process record:

• Write in a formal style if possible (e.g., “I am writing” instead of “I’m writing”).

• Use present tense when referring to past events unless there is some reason why you need to use some formality (e.g., discussing an error).

What is a Process Recording Used For?

Process recording is used to document the actions taken during a patient’s care. It is used to inform the next person who treats that patient, and it also helps improve patient care.

Process recordings are written by nurses or other health professionals as they work with patients in their daily duties. The process recordings can be found on paper forms or digital recorders such as EMRs (electronic medical records).

When are Process Recordings Written?

• When a patient is admitted to the hospital.

• When a patient is discharged from the hospital.

• When a patient is in the hospital for a long time.

• When there is an unusual condition or diagnosis, such as cancer or dementia, and it needs to be recorded as part of their record at each visit. This may also apply if someone has been admitted because they were feeling ill but had no idea what was wrong with them until they got here! It could also happen if someone has another condition like diabetes which requires regular monitoring at home too so that staff know what’s going on with them at all times (or wherever else they might go).

Is There Format for a Process Recording?

Yes, there is a format for a process recording. The format is:

• Introduction

• Problem statement

• Procedure (what you did)

• Results of your procedure (what happened) 

Takeaway:

A process recording is a written account of the steps taken to complete a task. It’s a way to ensure that you’re following the correct steps, and it also makes sure you’re doing things correctly.

Process recordings are often used when there are multiple people involved in an activity or task, so one person can observe how others are doing their jobs (or where they went wrong). For example: if I’m taking care of my bipolar sister, she might need medication refills every day at noon; but sometimes she forgets them until later in the evening when it’s too late for me to go get them myself—this could lead me down two different paths: either making sure I keep track of what would happen next if something were missing (e.g., “I’ll get this done tomorrow”), or keeping track of whether someone else has already done this before me so I’m not duplicating efforts unnecessarily (e.g., “Yesterday Julie said she’d take care of this”).

Conclusion

Process recording is a great way to document patient care and provide information on how the patient’s condition changes over time. It also helps you learn more about what works well or poorly in your department, which can help inform future changes.